In processing claim submissions (ie, “Claim” or “Claims”), including but not limited to clinical, financial, insurance or legal claims, the Claims can be, typically, a mix of unstructured and un-coded natural text. The Claims must be manually interpreted and compared to guidelines, policies, or profiles that describe criteria for subsequent downstream processing. A Claim can typically be accepted, declined, or redirected as appropriate for the business function.
As an example, when processing clinical disability Claims, Claims can be submitted via typical electronic sources including web applications, email, or fax. The Claim must then be evaluated according to evaluation guidelines. The guidelines are documents written to reflect policy, and are typically unstructured and un-coded natural text. Claims evaluators, people that manage the evaluation of Claims, use the guidelines to inform processing decisions such as accepting the Claim, declining the Claim, deferring for further analysis, or processing according to alternative means.
With unstructured and un-coded policies, the Claims evaluator must individually learn, translate, interpret and decide how to process each Claim leaving the Claim processing to a very manually intensive function. As such, the processing of Claims against unstructured and un-coded textual guidelines or policies is tedious, error prone, time consuming and expensive. As part of the Claim, the claimer's patient records can be retrieved from various healthcare institutions as evidence to the Claim.
A fundamental technical challenge facing the health care industry is that patient records are not interoperable across different sites of care. A key cause of this problem is that different sites use different data structures, data terminologies, and semantic interpretation. Unifying terminologies across various systems to an authoritative terminology is a key step in addressing this problem.
It is, therefore, desirable to provide methods and systems that overcome the shortcomings of the prior art, and to automate Claims processing against Claims guidelines or policies as an alternative to manual processing, and to enable properly contextualized semantic interoperability of patient data across data systems.